Summary The VA New York Harbor Healthcare System is a level 1b major interdisciplinary with two Community Based Outpatient Clinics (CBOCs) and three medical centers, which serve as teaching hospitals in Manhattan, Brooklyn, and Queens. Patients are served across hospital units such as, primary care, surgical, mental health care, outpatient, and emergency care. Responsibilities Functions or Scope of Assigned Duties: The Deputy Chief of Quality Management (QM) is a member of the executive administrative team and reports to the Director. The incumbent will work closely with the Chief of QM for ongoing oversight of all aspects of the healthcare system to ensure quality and minimize risk, and guides the organization through frequent interactions with other service chiefs. The Nurse IV Deputy Chief of Quality Management (QM) functions as an advisor, administrator, educator, consultant, and mentor who possesses a wide range of experience and leadership ability. Demonstrates performance that is broad enough to improve the care for a group of patients. The Deputy Chief of Quality Management (QM) executes leadership that is characterized by substantial and continuous responsibility and accountability for population groups or integrated programs that cross services and/or discipline lines and, influence the organizational healthcare mission. The Deputy Chief of QM is a self-directed nursing professional who supervises QM staff, assesses plans, implements, coordinates, monitors and evaluates the quality and safety of the delivery of care for the organization. Assumes a leadership role in facilitating regulatory compliance for internal and external oversight bodies (i.e., The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), Veterans Health Administration (VHA) Directives and Handbooks, etc.), Occupational Safety and Health Administration (OSHA), Office of the Medical Inspector (OMI), Office of the Inspector General (OIG), and VHA performance measures, supporting performance improvement work, and supporting and guiding the work of committees. The Deputy Chief of QM ensures that services have systems and processes in place to provide safe, quality care that is consistent with external benchmarks. Leads performance improvement initiatives by identifying quality metrics, trending data, maintaining the quality metric dashboard, and acts as a subject matter expert in data analysis and data display. Consults and acts as a resource to leadership and staff in standards interpretation implementation, patient safety, infection control, risk management, and re-design of processes and structures to improve care outcomes. Develops and implements policy and procedures, collaborates with service departments, and works toward meeting the strategic plan of the organization. The Deputy Chief of QM oversees monitoring of corrective actions from survey findings and assists services who are performance outliers. Provides oversight for programs such as the Joint Patient Safety Reporting (JPSR), Tort Claims, and Peer Review. Responsible for completing clinical quality reviews, clinical data analysis, and identifying opportunities for improvement. This includes providing clinical and administrative recommendations relative to all Strategic Analytic Improvement Learning (SAIL) outcomes, External Peer Review Program (EPRP) metrics, and driving improvement initiatives within the medical center. The Deputy Chief of QM collaborates with the Survey Coordinator for the coordination of accreditation readiness activities focused on standards compliance, education of staff on standards, VHA requirements, and customer satisfaction for internal and external stakeholders. Influences care outcomes by collaborating with members of the interdisciplinary team. Core elements of performance include knowledge and active participation in unit/program level quality improvement processes and initiatives as well as customer service programs. Leads QM staff through performance evaluations, provide guidance and support on culture changes, and change management projects. The Deputy Chief of QM supports all QM work to include but not limited to Accreditation, System Redesign, Infection Prevention, Patient Safety, Risk Management, High Reliability Organization (HRO), Just Culture, and evidence-based practices. Preferred Experience: Supervisory experience in QM department and knowledge of VHA performance measures. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: 8:00am-4:30pm, Full-Time Department/Unit: Quality and Patient Safety Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. You may be required to serve a probationary period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details. Qualifications Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. The following Scope, Education and Dimension criteria must be met to qualify for Nurse IV: Scope: Executes leadership that is characterized by substantial and continuous responsibility and accountability for population groups or integrated programs that cross service and/or discipline lines and influence organizational mission and health care. Education: Master's degree in Nursing (MSN) and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV; OR Master's degree in a *related field with a BSN and 4 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV; OR a Doctoral degree in nursing and 3 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV; OR a Doctoral degree in a *related field with a BSN and 3 years of professional nursing experience, one of which is specialized nursing experience equivalent to Nurse III and meets all dimension requirements for Nurse IV. *Note: Foreign education programs/degrees are not creditable as related degrees. Dimensions: Leadership. Leads health care delivery by leveraging evidence-based practices, industry-leading research, and innovative care models. Drives a shared vision and successfully leads change to improve performance and attain measurable outcomes at the program or service level. Business Acumen. Transforms health care by implementing new processes, technology, informatics, and data analytics using business models and fundamental concepts of resource management at the program or service level. Inspiring an Industry-Leading Culture. Employs an industry leading, shared decision-making culture. Cultivates a diverse and inclusive workforce that serves Veterans, families and caregivers of all backgrounds and builds trust, cultural competencies and catalyzes dynamic teams at the program or service level. Communication and Relationship Management. Directs the effective use of relationship management principles to achieve positive customer service experiences that are consistent with professional organizational values, beliefs and practices at the program or services level. Professional and Social Responsibility. Operationalizes a culture of holistic care, health advocacy and health equity. Applies ethical principles in decision-making at the program or service level. Advances nursing knowledge through health science research and the translation and dissemination of evidence into practice to maximize the value to Veterans and the community. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: See Handbook 5019 Education Additional Information This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.